February 27, 2015 katharina.janus

New on the Health Affairs Blog: Insights on how to build a framework to assess the impact of change

This post is part of a series of several posts related to the 4th European Forum on Health Policy and Management: Innovation & Implementation, to be held in Berlin, Germany on January 29 and 30, 2015. For more information or to request your personal invitation contact info@centerforhealthcaremanagement.org or follow @HCMatColumbia.

Building A Framework To Assess The Impact Of Change
By Theo Poiesz


Health care systems and organizations need to adapt to a rapidly changing societal and technical environment. In theory, this seems simple to do: policymakers and boards of organizations assess the nature of the developments, analyze the gap between the present and the desired situation, design a policy to reduce this gap, translate the policy in concrete measures, implement them, and reap the fruits of successful change — then start the cycle all over.

However, in the reality of daily practice, policies rarely have the intended effect and policy measures can lose effectiveness before they reach the intended point of impact. Sometimes, they may have the opposite impact than expected, raising costs for example, instead of reducing them.

Responding to Change

I believe this disconnect is a consequence of how health policymakers and organizations’ boards respond to change. As a professor and consultant in health care I have seen how they show a tendency to:

  • Diagnose problem situations more intuitively than systematically and analytically relying too heavily on past experiences. As a result historical situations frame the perception of new problem situations, even though the problems may differ. Analyzing possible future scenarios and their strategic implications is rather unpopular in health care compared to other sectors. For example, many health system leaders seem to assume that because it is a general and strong societal need, the survival of individual health care organizations is guaranteed. As a result they are more likely focus on near future organizational and network issues, than on longer term questions of organizational continuity in a changing world.
  • Respond to visible problems at the expense of more important, but often obscure, underlying causes. This is the problem of symptom driven policy. For example, they try to solve conflicts between employees instead of addressing the inherent friction in underlying organizational structures.
  • Take organizational and operational measures which are not aligned with the organization’s strategy. There seems to be an inclination to cooperate and network with other health care organizations, even if it is not clear if and how this advances the organization’s goals — as if cooperation is a goal in itself. Note that cooperation may even limit the organization’s room to maneuver strategically. For example, some organizations seem to view an extended network as a goal in itself, without doing careful cost-benefit analyses: a new partner may end up merely absorbing scarce resources without contributing to an organization’s strategic position.
  • Assume a direct link between an action and an effect: If we do this, then that will happen. Leaders are often preoccupied with determinants of success while ignoring potential failure factors.
  • Address different perspectives sequentially rather than simultaneously and integrally. For example, when different stakeholders have conflicting interests (not an uncommon occurrence in health care,) boards tend to address these interests one at a time, instead of devising an analytic scheme that approaches the conflict itself as a trade-off in achieving broader goal.
  • Aim for short-term successes (quick wins), instead of measuring the trade off between short-term and long-term effects.
  • Overemphasize internal compromises relative to coping with external threats. This might be due to the people-orientation which is relatively strong in the health care sector. Health care employees are naturally inclined to help people: people, both patients and colleagues, come before organizations and markets. As a result, internal frictions between individuals may be more disconcerting than a friction between their organization and the outside world, leading boards to spend a lot more time on internal relationships.
  • Follow conventional decision routines rather than considering innovative, more risky policy options. For example, innovation in health care is more likely to be ‘vertical’ in nature: providing improvements to established, proven routines. ‘Horizontal’ innovations involving unprecedented combinations of disciplines, sectors, and organizations—though relatively more popular in other sectors—are less common in health care.
  • Tackle problems by rearranging internal organizational structure—creating new departments, committees, functions, and responsibilities—merely shifting problems from place to place without addressing them directly. For example, if medical personnel do not fully comply with a protocol, a new position might be created to monitor their work, instead of dealing with the disciplinary issue itself.
  • Emphasize the improvement of existing processes while avoiding deeper strategic dilemmas. In a rapidly changing health care sector, the continuous emphasis on quality improvement may serve as an escape from possibly painful strategic decisions.
  • See quality in terms of compliance with official norms and procedures, rather than with the creation of unique and sustainable value for patients, clients, and society.

A Better Framework

Policymakers should adopt a decision framework that limits these tendencies while serving multiple functions: diagnosing a problem situation, suggesting an effective policy intervention, and assessing the impact of change.

In a sector that is characterized by increasing complexity, I believe that the development of such a decision framework should aspire to simplicity, guided by three principles: a focus on broader goals and determinants over any individual, and potentially irrelevant, details, as described by Dietrich Doerner in his 1996 book The Logic of Failure; limiting the framework to three independent dimensions along a continuous range of measurement (from less to more or earlier to later, for example); and the visualization of their combination as a cube.

These dimensions are chosen by identifying the dominant determinants of a desired outcome, then stripping away irrelevant details. For example, we may build a fire after considering myriads of details, but in the end it burns simply because of the combination of fuel, oxygen, and heat. The combination and interaction of those three dimensions is fundamental.

Under this framework, the three key dimensions that guide strategic decision making are:

  • the goal or mission at stake,
  • the resources available, and
  • the degree to which external conditions allow for change.

Similarly, a health problem may be assessed on the basis of:

  • level of need ranging from fundamental to superficial,
  • the seriousness of the complaint, and
  • the patient’s ability to cope independently.

And the development of health care may be represented by:

  • increasing patient orientation,
  • increasing focus on outcomes, and
  • increasing emphasis on long term effects.

Finally, the expanding health care market may be represented by:

  • increasing value as more suppliers are added,
  • the extension of health care process from diagnosis cure and care to also include prevention and reintegration, and
  • changing the conception of health care from only correction to include increased well-being as well.

Any set of three dimensions can be visualized as a cube, suggesting new analytical possibilities. For example, a board may analyze its organization’s position in the health care development cube described above, then monitor how that position migrates within the cube over time.

This simple framework, or decision cube, requires policymakers to consider fundamental dimensions simultaneously and integrally. It also highlights critical problem areas and suggests where interventions are needed most. They may even suggest the general nature of the required intervention.